Chiropractic vs. Medicine:
Who is More Cost Effective
& Renders Better Outcomes for Spine?
A report on the scientific literature
By: Mark Studin DC, FASBE(C), DAAPM, DAAMLP
When we consider mechanical spine issues, we need to consider problems exclusive of fracture, tumor or infection. According to Houweling Et. Al. (2015) back pain effects 43% of the population over the course of a year. In addition, 33% of that group reported that their symptoms led to reduced productivity at work. In Switzerland, this accounted for 3% of their gross domestic products and equates to $14 Billion in US dollars. Chiropractic’s forte` and focus historically has been mechanical spine issues and when considering who the first provider that should be consulted, one needs to examine the scientific evidence based upon outcomes so that rhetoric has no place in utilization and the facts control the argument and direction of the patient.
Simply put, where should a patient go first because it has been proven conclusively that it is the best place to get better. From an insurance carrier and legislative perspective, the question goes one step further and examines the cost of care and which is the best solution in a cost-effective care-path realizing that often the government is the insurer or risk taker and even private carriers have a fiduciary responsibility to their stockholders to ensure a profitable return, while offering the best possible solutions for their insureds.
Day Et. Al. (2007) reported that only 26% of fourth year Harvard medical students had a cognitive mastery of physical medicine (pg. 452). Schmale (2005) reported “Incoming interns at the University of Pennsylvania took an exam of musculoskeletal aptitude and competence, which was validated by a survey of more than 100 orthopaedic program chairpersons across the country. Eighty-two percent of students tested failed to show basic competency. Perhaps the poor knowledge base resulted from inadequate and disproportionately low numbers of hours devoted to musculoskeletal medicine education during the undergraduate medical school years. Less than 1⁄2 of 122 US medical schools require a preclinical course in musculoskeletal medicine, less than 1⁄4 require a clinical course, and nearly 1⁄2 have no required preclinical or clinical course. In Canadian medical schools, just more than 2% of curricular time is spent on musculoskeletal medicine, despite the fact that approximately 20% of primary care practice is devoted to the care of patients with musculoskeletal problems. Various authors have described shortcomings in medical student training in fracture care, arthritis and rheumatology, and basic physical examination of the musculoskeletal system (pg. 251).
With continued evidence of lack of musculoskeletal medicine and a subsequent deficiency of training in spine care, particularly of biomechanical [Subluxation] orientation, the question becomes which profession has the educational basis, training and clinical competence to manage these cases? Let’s take a closer look at chiropractic education as a comparison. Fundamental to the training of doctors of chiropractic according to the American Chiropractic Association is 4,820 hours (compared to 3,398 for physical therapy and 4,670 to medicine) and receive a thorough knowledge of anatomy and physiology. As a result, all accredited doctor of chiropractic degree programs focus a significant amount of time in their curricula on these basic science courses. So important to practice are these courses that the Council on Chiropractic Education, the federally recognized accrediting agency for chiropractic education requires a curriculum which enables students to be “proficient in neuromusculoskeletal evaluation, treatment and management.” In addition to multiple courses in anatomy and physiology, the typical curriculum in chiropractic education includes physical diagnosis, spinal analysis, biomechanics, orthopedics and neurology. As a result, students are afforded the opportunity to practice utilizing this basic science information for many hours prior to beginning clinical services in their internship.
To qualify for licensure, graduates of chiropractic programs must pass a series of examinations administered by the National Board of Chiropractic Examiners (NBCE). Part one of this series consists of six subjects, general anatomy, spinal anatomy, physiology, chemistry, pathology and microbiology. It is therefore mandatory for a chiropractor to know the structure and function of the human body as the study of neuromuscular and biomechanics is weaved throughout the fabric of chiropractic education. As a result, the doctor of chiropractic is expert in the same musculoskeletal genre that medical doctors are poorly trained in their doctoral education as referenced above.
A 2005 study byDeVocht, Pickar, & Wilder concluded through objective electrodiagnostic studies (neurological testing) that 87% of chiropractic patients exhibited decreased muscle spasms.This study validates the reasoning behind the later study that people with severe muscle spasms in the low back respond well to chiropractic care and this prevents future problems and disabilities. It also dictates that care should not be delayed or ignored due to a risk of complications.
The above statistic indicates that while medicine cannot conclude an accurate diagnosis in 85% of their back pain patients, chiropractic has already helped 87% of the same population. We also know that chiropractic is one of the safest treatments currently available in healthcare for spinal treatment and when there is a treatment where the potential for benefits far outweighs any risk, it deserves serious consideration. Whedon, Mackenzie, Phillips, and Lurie(2015) based their study on 6,669,603 subjects after the unqualified subjects had been removed from the study and accounted for 24,068,808 office visits. They concluded, “No mechanism by which SM [spinal manipulation] induces injury into normal healthy tissues has been identified”(p. 5).
Houweling Et. Al (2015) concluded “Patients who initially consulted with MDs were significantly less likely to be satisfied with the care received and the results of care compared with those who initially consulted DCs” (p. 480) and Adjusted mean costs per patient were significantly lower in patients initiating care with DCs compared with those initiating care with MDs. (p.480) “The findings of this study pertaining to patient satisfaction were in line with previous research comparing chiropractic care to medical care for back pain, which found that chiropractic patients are typically more satisfied with the services received than medical patients.” (p.481)
Houweling Et. Al (2015) continued “Mean total spinal, hip, and shoulder pain-related health care costs per patient during the 4-month study period were approximately 40% lower in patients initially consulting DCs compared with those initially consulting MDs. The reason for this difference was a lower use of health care services other than first-contact care in patients initially consulting DCs compared with those initially consulting MDs. Previous observational studies comparing medical and chiropractic care in terms of health care costs per patient have shown opposing results. Two studies conducted in the United States found that patients with low back pain treated in chiropractic clinics incurred higher costs than patients treated in medical clinics. One possible reason for these opposing findings is that differences were brought about by the methods of determining costs. In the studies conducted in the United States, costs were determined by chart audit, whereas in the present study, cost determinations were based on an insurance database review of all health care services used for the conditions investigated including the cost of visits to other health care providers.” Pg. 481
Perhaps the most telling point of Houweling Et. Al (2015) results were “Restrictive models of care in which patients are required to contact a medical provider before consulting a chiropractic provider may be counterproductive for patients experiencing the musculoskeletal conditions investigated and possibly others. In addition to potentially reducing health care costs, direct access to chiropractic care may ease the workload on MDs, particularly in areas with poor medical coverage and hence enabling them to focus on complex cases. The minority of patients with complex health problems initially consulting a chiropractic provider would be referred to, or co-managed with, a medical provider to provide optimal care. (p.481)
The above model not only suggests, but verifies that chiropractic should be the first choice or the primary spine care provider freeing up an already overburdened medical primary care provider’s office where they are not qualified to manage mechanical spine issues as reported above. This also helps resolve some of the issues in more rural regions where there is a shortage of primary care medical providers and positions the public to realize better outcomes and serves the insurers by ensuring lower costs.
Headaches & Migraine: Chiropractic vs. Medication
Effectiveness & Safety
In randomized clinical trials, chiropractic was 57% more effective in the reduction of headaches and migraines than drug therapy
A report on the scientific literature
By Mark Studin DC, FASBE(C), DAPM, DAAMLP
It was reported in October of 2010 by Wrong Diagnosis that approximately 1 in 6,16.54% or 45 million Americans get headaches yearly, with many people suffering daily. While the statistical numbers vary based upon your source of information, it can be agreed upon that headaches are very common and shared among Americans at an epidemic rate. Taking into account that a single pill for many Americans to treat a headache can cost as much as $43, according to Consumer Reports Health Best Buy Drugs, the overall cost to our economy totals billions of dollars and we need to focus not on the treatment of the effects, but the root of the cause.
When you suffer from headaches, it affects every facet of your life and you search for immediate answers. Most often it is a medication, either over-the-counter or prescription as evidenced by the amount of money spent as previously reported. One of the first medications recognized for the potential treatment of headaches is amatriptyline, commonly known by brand names such as Elavil, Endep or Amitrol as reported by Robert on About.com in 2006. It is also used as an antidepressant. This medication has made up a large part of the billion dollar industry along with over-the counter-medications. Although in many instances, this drug is indicated, the question that arises is what are the risks of taking this widely used medication?
The potential side effects of this medication targeted for headache sufferers, according to drugs.com (n.d.), are: blurred vision, change in sexual desire or ability, constipation, diarrhea, dizziness, drowsiness; dry mouth, headache, loss of appetite, nausea, tiredness, trouble sleeping, and weakness. Severe allergic reactions can be: rash, hives, itching, difficulty breathing, tightness in the chest, swelling of the mouth, face, lips, or tongue, chest pain, confusion, dark urine, delusions, difficulty speaking or swallowing, fainting, fast or irregular heartbeat, fever, chills, or sore throat; hallucinations, new or worsening agitation, anxiety, panic attacks, aggressiveness, impulsiveness, irritability, hostility, exaggerated feeling of well-being, restlessness, or inability to sit still, numbness or tingling in an arm or leg, one-sided weakness, seizures, severe or persistent dizziness or headache, severe or persistent trouble sleeping, slurred speech, suicidal thoughts or actions, tremor, trouble urinating, uncontrolled muscle movements (such as in the face, tongue, arms or legs), unusual bleeding or bruising, unusual or severe mental or mood changes, vision problems, and yellowing of the skin or eyes. Over the counter remedies of NSAID's or aspirin have a long list of their own of side effects.
The safety of chiropractic, in spite of rhetoric from naysayers, has been documented in clinical trials by Miller and Benfield (2008), who reported on children younger under 3 years old, "the youngest and most vulnerable population..." (p. 420). There was one reaction reports for every 749 adjustments which was typically crying. None were reported to have any serious side effects.
In adults, clinically, the majority of any side effects are soreness that is transient. This is based upon this author's 30 years of clinical experience and teaching doctors of chiropractic who are trained in creating an accurate diagnosis, prognosis and treatment plan. To say that more serious side effects cannot happen is irresponsible. However, they are rare, non-life threatening and usually transient in nature, no different than infants. To ensure the best outcomes, like with any professional, you have to verify the doctor's credentials and experience, which is best accomplished by securing a copy of the doctor's curriculum vitae (his/her academic and professional credentials).
Nelson et. al. (1998) reported on randomized clinical trials that took place over an 8-week course. The results showed there was minor statistical differences in outcomes for improvement during the trial period for chiropractic care, amatriptyline and over-the-counter medications for treating migraine headaches. It was also reported that there was no statistical benefit in combining therapies. However, the major factor is that in the post-treatment follow-up period, chiropractic was 57% more effective in the reduction of headaches than drug therapy.
Bryans, et. al. (2011) confirmed Nelson's findings and reported that spinal manipulation (adjusting) is recommended for patients with episodic or chronic migraines with or without aura and patients with cervicogenic headaches. This follow-up study is not a comparison or comment on the use of drugs. It simply demonstrates that chiropractic is a viable solution for many and can save the government and private industry billions in expenditures both in health care coverage, loss of productivity and avoidance of absenteeism in industry creating a new level of cost as sequella to headaches.
Medications and other forms of invasive care are often necessary and it is critical for a trained doctor to perform an accurate history and physical and when indicated, advanced diagnostic testing (CAT scans, MRI's, etc.) to ensure there aren't more serious underlying complications. However, based upon the results of the research provided by Nelson et al. (1998) and Bryans et. al. (2011), it should be chiropractic first, drugs second and surgery last to render better outcomes with less potential side effects and a quicker return to productivity.
1. Wrong Diagnosis. (2010, October 6). Prevalence statistics for types of headaches and migraine conditions. Health Grades Inc. Retrieved from http://www.wrongdiagnosis.com/h/headache_and_migraine_conditions/prevalence-types.htm
2. Consumer Reports Health Best Buy Drugs. (n.d.). Treating migraine headaches: The triptans, Comparing effectiveness, safety, and price. Health.org. Retrieved from http://www.consumerreports.org/health/resources/pdf/best-buy-drugs/triptanFINAL.pdf
5. Miller, J. E., & Benfield, K. (2008). Adverse effects of spinal manipulative therapy in children younger than 3 years: A retrospective study in a chiropractic teaching clinic. Journal of Manipulative and Physiological Therapeutics, 31(6), 419-423.
6. Nelson, C. F., Bronfort, G., Evans, R., Boline, P., Goldsmith, C., & Anderson, A. V. (1998). The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. Journal of Manipulative & Physiological Therapeutics, 21(8), 511-519.
7. Bryans, R., Descarreaux, M., Duranleau, M., Marcoux, H., Potter, B., Ruegg, R.,... White, E. (2011). Evidenced-based guidelines for the treatment of adults with headache. Journal of Manipulative & Physiological Therapeutics, 34(5), 274-289.